Hannah Melissa Ilagan, RN Michelle M.

Luceno, RN

 The nursing process is an organized sequence of problem- solving steps used to identify and to manage the health problems of clients.

 Characteristics: Within the legal scope of nursing Based on knowledge Planned Client- centered Goal- directed Prioritized Dynamic

Assessment 1. Collect data 2. Organize data Evaluation 1. Monitor the client outcomes 2. Resolve, continue, revise the current plan of care Diagnosis 1. Analyze data 2. Identify nx dx and collaborative problems

Implementation 1. Carry out the nursing orders 2. Document the nursing care and client responses

1. 2. 3. 4.

Planning Prioritize problems Identify measurable outcomes Select nursing diagnosis Document the plan of care

 The first step in the nursing process, is the

systematic collection of facts, or data.

Begins with the nurses first contact with a client

and continues as long as a need for healthcare exists.

During assessment, the nurse collects information

to determine areas of abnormal function, risk factors that contribute to health problems, and clients strengths.

Objective Data
observable and

Subjective Data
Consists of information

measurable facts
Referred to as signs of a

that only the client feels and can describe

Referred to as symptoms
E.g.: pain, nausea,

disorder
E.g.: wt, temp, skin

color, blood pressure, vomiting, bleeding, blood cell count

depression, fatigue, anxiety, loneliness

 Sources for Data

1. Primary- Client 2. Secondary- Clients family, reports, test results, information in current and past medical records, discussions with other healthcare workers.

 Types of Assessments
Data Base Assessment
Obtained on admission Consists of predetermined questions and systematic head-to-toe examination Performed once Suggests possible problems Findings documented on an admission assessment form Time- consuming; may take 1 hr or more

Focus Assessment
Complied through subsequent care Consists of UNSTRUCTURED questions and collection of physical assessments Repeated each shift or more often Rules out or confirms problems Finding documented on a checklist or in progress notes Completed in a brief amount of time ( about 15 mins)

 Types of Assessments
Data Base Assessment
Supplies a broad, comprehensive volume of data Provide breadth for future comparisons Reflects the clients condition on entering the health care system

Focus Assessment
Collects limited data Adds depth to the initial data base Provides comparative trends for evaluating the clients response to treatment

 Organization of Data

- Organization involves grouping related information.

- Data organized into small groups is more easy to analyze and takes on more significance than when the nurse considers each fact separately or examines the entire group at once.

 the 2nd step, is the identification of health- related

problems

Diagnosis results from analyzing the

collected data and determining whether they suggest normal or abnormal findings

NURSING DIAGNOSIS- is a health issue that can be

prevented, reduced, resolved, or enhanced through independent nursing measures.

NURSING DIAGNOSIS- is an exclusive nursing

responsibility.

It can be categorized into 5 groups: Actual Risk Possible Syndrome Wellness

TYPE
Actual Diagnosis

EXPLANATION AND EXAMPLE

A problem that currently exists. Impaired Mobility related to pain as evidenced by limited range of motion, reluctance to move A problem the client is uniquely at risk for developing. Risk for deficient fluid volume related to persistent vomiting

Risk Diagnosis

Possible Diagnosis

A problem may be present, but requires more data collection to rule out or confirm its existence. Possible Parental Role Conflict related to impending divorce
Cluster of problems predicted to be present because of an event or situation. Rape Trauma Syndrome and Disuse Syndrome A health-related problem with which a healthy person obtains nursing assistance to maintain or perform at a higher level. Potential for Enhanced Breastfeeding

Syndrome Diagnosis

Wellness Diagnosis

DIAGNOSTIC STATEMENTS
Contains 3 parts:

1. 2. 3.

Name of the health- related issue or problem as identified in the NANDA list Etiology Signs and Symptoms

*the name of nx dx (related to)- etiology, (manifested by) signs and symptoms

Different types of diagnoses have different stems Potential diagnoses are prefaced with the term risk
for, as in Risk for Impaired Skin Integrity related to inactivity.

The word possible is used in a diagnostic

statement to indicate uncertainty- example, Possible Sexual Dysfunction related to anxiety

Wellness Diagnosis prefaced with phrase Potential

for enhanced

 Collaborative Problems are physiologic

complications whose treatment requires both nurse and physician prescribed interventions.

Nursing Diagnoses

Collaborative Problems

Medical Diagnoses

 is a deliberative, systematic phase of the nursing process that involves decision-making and problem solving.
In planning, the nurse refers to the clients assessment data and diagnostic statements for direction in formulating the clients goals and designing the nursing interventions required to prevent, reduce, or eliminate the clients health problems.

 TYPES OF PLANNING Initial planning- the nurse who performs the admission assessment usually develops the initial comprehensive plan of care. - this nurse has the benefit of the clients body language as well as some intuitive kinds of information that are not available solely from the written database. - planning should be initiated as soon as possible after the initial asessment.

 TYPES OF PLANNING Ongoing planning- is done by all nurses who work with the client. As nurse obtain new info and evaluate the client responses to care, they can individualize the initial care plan further.
-It also occurs at the beginning of a shift as the nurse plans the care to be given that day.

Using ongoing assessment data, the nurse carries out daily planning for the ff purposes: 1. to determine whether the clients health status has changed 2. To set priorities for the clients care during the shift 3. to decide which problems to focus on during the shift 4. To coordinate the nurses activities so that more than one problem can be addressed at each client contact.

Discharge planning- the process of anticipating and planning for needs after discharge. Developing nursing care plans The end product of the planning phase can be: Informal NCP- a strategy for action that exists in the nurses minds. Formal NCP- a written or computerized guide that organizes information about the clients care. This provides more continuity of care.

Standardized care plan- a formal plan that specifies the nursing care for groups of clients with common needs.

Individualized care plan- tailored to meet the unique needs of a specific client (needs that are not addressed by the standardized care plan).

Formats of NCPs The care plan is often organized into four columns or categories: I. Student Care Plans a. Nursing diagnosis b. Goals/ Desired outcomes c. Nursing orders d. Evaluation (e.) Rationale II. Computerized Care plans- nurses access the clients stored care plan from a centrally located terminal at the nurses station or from terminals in client rooms.

 Guidelines for writing NCPs: 1. Date and sign the plan 2. Use category headings 3. Use standardized medical or English symbols and key words rather than complete sentences to communicate your ideas. (e.g. Turn and reposition q2h) 4. Be specific. (working shifts) 5. Refer to procedure books or other sources of information rather than including all the steps on a written plan.( e.g. see unit procedure book for tracheostomy care.

 Guidelines for writing NCPs: 6. Tailor the plan to the unique characteristics of the client by ensuring that the clients choices, such as preferences about the times of care and the methods used, are included. 7. Ensure that the plan contains interventions for ongoing assessment of the client. (e.g. Inspect incision q8h) 8. Ensure that the NCP incorporates preventive and health maintenance aspects as well as restorative ones. (e.g. Provide active ROM exercises to affected limbs)

 Guidelines for writing NCPs: 9. Include collaborative and coordination activities in the plan. (e.g. Ask a physical about ROM exercises) 10. Include plans for the clients discharge and home care needs. (e.g. ask to make arrangements with the CHN, social worker) SETTING PRIORITIES The process of establishing a preferential sequence for addressing nursing diagnoses and interventions.

ESTABLISHING CLIENT OUTCOMES AND GOALS In terms of observable client responses, what the nurse hopes to achieve by implementing the nursing interventions. SELECTING NURSING INTERVENTIONS a. Independent interventions- those activities that nurses are licensed to initiate on the basis of their knowledge and skills. b. Dependent interventions- activities that are carried out under the physicians orders or supervision, or according to specified routines.

WRITING NURSING ORDERS Are instructions for the specific individualized activities the nurse performs to help the client meet established health care goals.
DATE
Are dated when they are written and reviewed regularly at intervals that depend on the individuals needs.

ACTION VERB

CONTENT AREA

TIME ELEMENT

SIGNATURE

Starts the order and must be precise.

Answers when, how The what and long, or how the where ond often the the order. nursing action is to occur.

The signature of the nurse prescribing the order shows the nurses accountability and has legal significance.

consists of doing and documenting the activities that are the specific nursing actions needed to carry out the interventions.

The nurse delegates the nursing activities for the interventions that were developed in the planning step and then concludes the implementing step by recording nursing activities and the resulting client responses.

To implement the care plan successfully, nurses need cognitive, interpersonal, and technical skills. Cognitive skills- include problem solving, decision making, critical thinking, and creativity. Interpersonal skills-all of the activities, verbal and nonverbal, people use when interacting directly with one another. Technical skills- hands on skills.

Process: 1. Reassessing the client 2. Determining the nurses need for assistance 3. Implementing the nursing interventions 4. Supervising the delegated care 5. Documenting nursing activities.

is a planned, ongoing, purposeful activity in which clients and health care professionals determine: a. The clients progress toward achievement of goals/ outcomes b. the effectiveness of the nursing care plan. An important aspect because conclusions drawn from the evaluation determine whether the nursing interventions should be terminated, continued, or changed.